Daniel Brotman, Academic Hospitalist

 

119.Daniel Brotman

SPEAKERS

Will Bachman, Daniel Brotman

 

Will Bachman  00:02

Bill, hello and welcome to the 92 Report. I’m your host. Will Bachman, and I’m delighted to be here today with Dan Brockman. Dan, welcome to the show.

 

Daniel Brotman  00:11

Thanks. Will appreciate having me. And wow, it’s hard to imagine how long it’s been since we graduated from undergrad. So it’s been, it’s been quite a journey. So after I finished in 92 I did a year of research in the Boston area in circadian rhythms. I knew I wanted to go to medical school, but because I’d been so busy with the Harvard callbacks as beauty director my senior year that group, I didn’t, I didn’t get around to applying for medical school. So you were too busy

 

Will Bachman  00:54

with the callbacks to apply to medical school. Yeah?

 

Daniel Brotman  00:58

Well, that was pretty much it, yeah. I figured. I figured I wanted to enjoy my senior year rather than have it be completely stressful. So all right, so I did.

 

Will Bachman  01:12

So So you basically just put off applying, and figured, okay, I’ll work for a year. I’ll apply next fall when I’m relaxed. Wow, okay, yeah, you’d already had, you already taken the MCATs and stuff, or

 

Daniel Brotman  01:23

I had taken the MCATs and one of the things I taught Stanley Kaplan some during my year off, in addition to working in the lab at the Brigham and Women’s Hospital, I actually worked in the building where I was born. So

 

Will Bachman  01:39

feels like home. Exactly. And before you get into the whole story, I got to ask, almost in advance, you were in the callbacks. Did you has singing continued to play some form of your life or music post Harvard music,

 

Daniel Brotman  01:53

for sure. You know, I always considered myself a better musician than singer, you know, a good ear. And and love playing piano. So I have my my grandmother’s 1930 Steinway, which is the only earthly possession I’m actually attached to. And and I did play and sing some in bars when I did go to med school at University of Virginia. And I still, I still play it for fun. The the most recent incarnation of that is piano karaoke, because I’ve got a good enough year that I can, I can turn on, like, pop songs and play along with them, and then if other people want to sing along, you know, it’s got the same pace and cadence and and general vibe as the song they’re used to hearing on the radio. So that can be kind of fun. So I’ve been doing that some when we have gatherings at our house,

 

Will Bachman  02:52

that’s awesome. It’s so nice talking to Harvard alum several other guests have you know, told me about how they were in a music group at Harvard, and they’ve continued to, you know, participate in that, or they’ve joined some singing group. So that’s very cool, okay, but before we go on past your your your research circadian rhythms. Tell me something about circadian rhythms. It’s, uh, what? What should we know about circadian rhythms.

 

Daniel Brotman  03:21

So circadian rhythms just refers to circa means about, and DN is day, so it’s about a day. And circadian rhythms are rhythms that that cycle through your body based on the action of the circadian pacemaker, which lives in the suprachiasmatic nucleus of the hypothalamus. So circadian rhythms get synchronized to the 24 hour day based on mainly visual stimuli light coming into keep your your rhythm synchronized to the 24 hour day. So if you have people that that live in complete darkness, they will get out of sync with the 24 hour day oftentimes. So so

 

Will Bachman  04:14

I was a submarine officer, so I I’m totally hearing that we is it true that some people naturally, just biologically, are, like, night owls, and some people are larks, and some people in between? Like, do people just, some people just naturally perform better, like, late at night, or,

 

Daniel Brotman  04:34

yeah, you know, I mean, all these people are still synchronized, and there’s actually a hypothesis that that is been put forth that I think makes a fair amount of sense, which is that, that when you’re a teenager, you’re you tend to be a night owl, and part of that is adaptive, so that teenagers can sort of, if you think about. Clans of cave people. You know, they can go out and do their thing late in the day. Mom and Dad wake up early in the morning. And you know it helps to have, you know, wakefulness for a longer period of time throughout the 24 hour day, if you’re a clan of cave dwellers, right? Because, okay, somebody’s going to be up, and it’s the teenagers if it’s late in the evening, and it’s the grandparents if it’s first thing in the morning. So there’s definitely a trend, you know, whereby teenagers tend to be night owls and old people tend to be, you know, early risers, and that’s, you know, across across cultures, and I think has some evolutionary value if you live in a big cave, growing clan, I suppose, fending off from the saber tooth tigers. Okay,

 

Will Bachman  05:59

cool. So I jumped into your story there. So you were so post year you were applying to medical school. You obviously got accepted. So continue on with your story where I interrupted. Well,

 

Daniel Brotman  06:12

yeah, I ended up going to University of Virginia. My roommate, college roommate, Dallas Reg, was getting a PhD in computer science down there. And it hadn’t even occurred to me to venture out of New England, but he encouraged me to go interview down there. And I really loved it. It was a, it was beautiful, beautiful place, and full of, full of tradition and and, you know, great place to go to medical school. So, you know, I started there after after my year doing research. And, you know, went through four years I knew I didn’t want to do internal medicine when I when I got there, so I let everybody else do it in the beginning of their clinical rotations, because word on the street was it was a good thing to do it early so that you could get some foundation. And it was broad and understanding, you know, how to interview patients and so on. But to my surprise, at the end of my third year, I actually discovered I liked internal medicine. So ended up, ended up deciding to come to Hopkins for that. While I was in med school, I did meet my my first wife, Edith. She was a grad student in Sociology at the time, and we got married, along with many of my classmates the the last year at medical school, which you know is a convenient time, because when you go off for residency, it means that you don’t have to date anybody. It’s hard to date people in residency, it’s a little easier now than it used to be, but you know, I was working 100 hour weeks, wow.

 

Will Bachman  08:01

And so you graduate from medical school, and you went off to what was next. So

 

Daniel Brotman  08:08

came to Hopkins for residency in Internal Medicine, the Osler, Osler residency program. So it’s one of the, you know, first, first residency programs in internal medicine in the in the nation, and also a lot of tradition there. And I ended up deciding I wanted to be a hospitalist. So what most people, particularly in that era, went on to sub specialties. So did additional training in cardiology or pulmonology or gastroenterology or what have you. I wanted to get out and practice, and I liked inpatient medicine and acuity at that point. You know, I already had a young family. My son, Parker, was born when I was a second year resident and needed to put the food on the table, and did not particularly want to be in a job that was similarly the 100 hour a week. Kind of flavor fellowships usually not quite that bad, but it was pretty intense back then. So still pretty intense. So I went to the Cleveland Clinic as a hospitalist there. And, and that’s where I kicked off my my career hospital medicine was a pretty new field then, and so was sort of coming in at the ground floor.

 

Will Bachman  09:47

And what is it to me? What does it mean to be a hospitalist?

 

Daniel Brotman  09:50

So I don’t have an outpatient practice, and the patients I see are in the hospital most often. You know? They. Come in through the emergency room and and they need a an inpatient doctor to help them through their acute illness, and that may be me or one of my team members, but we also help surgeons care for their patients who have medical issues, or help other disciplines care for their patients when they have medical issues as consultants. So, you know, really, what hospital is. Hospital Medicine is defined by by the site of practice being in the hospital, the way that an emergency room medicine doc practices in the emergency department. So, you know, I trained in internal medicine, became an internal medicine hospitalist, but there are pediatric hospitalists and OB hospitalists and neuro hospitals nowadays who are defined again by practicing in the hospital rather than having outpatient practices.

 

Will Bachman  10:56

And then I think after Cleveland Clinic, you stayed there for a few years and went back to Hopkins.

 

Daniel Brotman  11:03

Yeah, you know. So I, I had asked the folks at Hopkins, before I went to the Cleveland Clinic, whether they were interested in having a hospitalist program, and I was told, I was told, No, that they weren’t particularly interested in that. And then two years later, I got called, and they said, We’re starting up a hospitalist program. Would you like to come start up? And I said, you know, I, I have bought a house in Cleveland, you know, I got a young family. I am not particularly keen to move so not, not really. And the person who called me was, his name’s John Flynn. He’s was my, one of my faculty mentors when I was, when I was in residency, and and he Yeah, so he, he would call me periodically to check in and see whether I might be in a different state of mind and want to come back and about so in 2005 so five years after I’d been at the Cleveland Clinic, it felt like I was potentially interested in in a change of pace. You know, I did. I did talk to when I talked to John, he was funny. I when he started calling me up to see if I wanted to come back, I said, you know, you didn’t want to have a hospital medicine program when I was there. And now I leave and you want to have one, it’s sort of like, you know, your high school girlfriend calling you up to see whether you want to get back together again. And John says, Well, do you still have feelings for

 

Will Bachman  12:48

what? Tell me a bit about some of the things that you know now, advice that you would have given your younger hospitalist self, lessons that you’ve learned over the years.

 

Daniel Brotman  13:04

Wow, so, so, you know, some of these things are just lessons about being a doctor, and so one of, one of the, one of the most important lessons is you got to have some degree of humility, because you can’t you can’t take care of patients by yourself. You need a functioning team. You need to work with nurses and social workers and other folks who help you take care of patients, and you’re only as good as your team is. So even if you’re considering yourself and other people are considering you the quarterback you know, you know quarter quarterback all all by himself, doesn’t, doesn’t make for a good team. So, so, so you know, have have some humility in that regard. Also, you know, have some humility when it comes to recognizing that everybody you know has things to learn and makes mistakes and, and, and also, one of the things that’s most interesting in the humility arena relates to how quickly medicine gets out of date. The things that they taught us in medical school, many of those concepts are still very, very valid, but some of them have been completely turned on their heads.

 

Will Bachman  14:35

So can you give me an example?

 

Daniel Brotman  14:37

Yeah, well, one of the best examples is beta blockers and heart failure. So So beta blockers, block the body’s adrenaline, slow the heart rate down and decrease the pumping activity of the heart. And so what they taught us when I was in medical school is, if you’ve got a weak heart muscle, the last thing in the world. Role you want to give that person as a beta blocker? Why? Because it’ll drive them into congestive heart failure. Worse, you cut down on the hearts pumping activity when they really, really need it the most. And made perfect sense, but it turns out that it’s now a mainstay of treatment of heart failure, because they did studies showing that the overdrive of adrenaline that was stimulating the heart to try to squeeze harder in patients with heart failure was damaging the heart muscle more, and so what the heart muscle really needed was a rest, and beta blockers allowed that to happen. So the people who do who get the most benefit from from beta blockers are actually the people with the weakest heart muscles

 

Will Bachman  15:48

in a case like that. Have you found that some doctors might be very quick to adopt the latest research from journals, and are there some that actually continue to believe this outdated, wrong belief, and they don’t kind of adopt to the research, like, what Tell me about that spectrum that you see? I mean, on the one hand, you don’t want to just jump on the latest academic article, because maybe it’s wrong. Maybe it’s just a one off, right? So talk to me about that kind of spectrum of adoption.

 

Daniel Brotman  16:27

Yeah, that’s, that’s a great point. I’m glad you brought up the the second counterpoint, which is that you, you don’t want to, you know, gravitate toward every new, shiny object that’s published in the medical literature, and I’ve seen instances of that too, where there are, you know, new strategies that seem so good that they might be too good to be true, and sometimes they turn out to be too good to be True. And and with more experience either side effects or, or, you know, challenges with with how well it a new drug, for instance, works, and follow up trials are identified. So, so I think there is a Goldilocks phenomenon, right? You don’t want to be a doctor who who doesn’t update your your your repertoire over time as new evidence emerges. But you also don’t want to jump on every new strategy, you know, as if it’s the best thing since sliced bread, you know, and that’s how you can get into trouble. And there’s a lot of crappy medical research out there that gets published, and we saw some of that during COVID and and it can really be be a problem if you, if you look at one positive study and run with it. So, so I think, you know, one of the things that oftentimes we do is rely on society guidelines, which tend to be pretty good as pretty boring, right? Because just following guidelines makes you feel like you’re, you’re, you’re just following a cookbook rather than taking care of patients. But you know, when in doubt, I think look for look for guidelines, and those have been synthesized by by people who really know the literature and have thought about all these issues and come up with a synthesis that makes sense. And in most cases, yes, they’ll get updated over time, but they’re they’re not going to change dramatically overnight, but they’ll also recognize when there’s game changing, new medications and strategies that can really help our patients, and you know, put those out in a in a carefully written way. All

 

Will Bachman  18:56

right, so you’re going through some lessons. You’re talking about humility, talking about how people make mistakes. How did you learn that lesson of humility? When you say it’s a lesson, does that mean that when you came out of medical school, you were kind of had the like, I’m a superhero, I can handle it myself. And then you had to learn that lesson hard way. Or,

 

Daniel Brotman  19:13

you know, one of the things that really attracted me to Hopkins as a residency program when I went there was that it was a place that really had an ethos that that, you know, junior doctors should be really taking on a lot of autonomy. And I think for the most part, that was a really great strategy to train people to be doctors, but it does have, you know, sometimes a side effect of making young doctors a little bit cocky with their own skill set, and that can be a challenge. And I think that, you know, I certainly think that that happened. With me to some extent, and many of my colleagues, you know, it’s not to say that I wasn’t a good doctor for somebody right out of residency, but there’s a big difference between somebody right out of residency and somebody

 

Will Bachman  20:16

a few years out. Can you think of a example, or some anecdote that happened that helped you learn that kind of humility, that helped you learn like, wow, I’m not all powerful, but I really need to rely on the nurses and the rest of the team. You know.

 

Daniel Brotman  20:36

You know, that’s a really good question, and I probably should have have a good answer for that, but I think it’s really more recognizing that patient safety is a genuine concept, right? So for instance, you know, I don’t do a good job as a doctor preventing patients from getting bed sores. But you know, when patients get bed sores, bad things happen. They some of them die and and doesn’t take a rocket scientist to, you know, follow guidelines and put patients on on injectable blood thinners to keep them from getting blood clots in the hospital. But, you know, that’s an easy thing, just to forget, or you stop it because somebody’s undergoing a neurosurgical procedure and you could forget to restart it, and just, you know, these little things that that that really have a big impact for patients are often better being owned by by In the former case, nurses who do a much better job with skincare than doctors. And in the latter case, IT systems that remind you when the blood thinning treatment that everybody should be on in the hospital when they meet certain criteria has, you know, fallen off the patient’s medication list, and so I don’t think it’s so much particular instances where I’ve been humbled or humiliated in a way that that that you know, really hurt a patient based on my lack of knowledge, so much As just realizing how complicated healthcare is and that that that it’s easy for things to fall off the radar if you don’t have colleagues and systems that can pick up the slack.

 

Will Bachman  22:38

I’m curious your take on all these new AI tools that are coming out. I’ve kind of from a distance, I’ve sort of observed and heard, you know, there’s AI tools that will maybe listen in to a doctor’s conversation with the patient, then make a transcript of that, and then add the notes to the person’s chart, and all these kinds of AI tools and other things that might recommend interventions, or I’m curious what you’re seeing happening with that, and how you thinking that might play out over the next period of months. It’s hard to predict years, you know. But what do you see going on there?

 

Daniel Brotman  23:11

Yeah, that’s a great that’s a great question. I think, yes, we are using AI to help with their documentation nowadays. So there’s a tool that we’re using at Hopkins now. It’s called a bridge, which is an AI tool that listens to your discussion with a patient and crafts a note based on that. I think it’s very effective at certain things, but, but, you know, my interactions with patients are pretty conversational, and I think it can be really hard for any AI tool to, you know, really put things fully in context. It’s gotten better just in a short period of time. You know, concrete example would be that it had a tendency to put components of a physical exam and a history of present illness. So, you know, if I were to say at the bedside, I’m examining your legs, and there doesn’t seem to be edema, you know, talking to the patient, letting them know what I’m seeing, it might report, you know, that the patient denies edema, and which is not what that’s intended to convey. But yeah, it’s pretty impressive that, you know, without looking at anything, just hearing it and hearing different voices, it can, it can create some semblance of a note. I do think that we will see areas where it makes errors and busy. Doctors don’t correct those errors. I think that’s, you know, that’s That’s always one of the challenges when you’re using technology to help you practice medicine. You know, the consequences of screwing up can be pretty, pretty important and and if you become excessively reliant on tools that are helping you take care of patients, and the tool doesn’t work perfectly, but you don’t double check behind it, bad things might happen. So you know, with documentation, I think there’s enough slop and challenges with our current documentation, regardless of how we do it, that that I think AI is a win when it comes to, you know, making recommendations for treatment strategies. I think it’s also going to be a win, you know, and we already use this to some extent. I mean, if you go into chat GPT and say, I’m having the following symptoms, and here’s my age and sex and medical history, you know, I would imagine it could at least give you some valid information about where you know what things to consider, but it’s not going To it’s not going to give you a diagnosis, and, or at least it shouldn’t. It should give you some ideas. And I think that physicians alike are going to be, you know, increasingly using AI to to help them, you know, prompt them to get their their their work, their work done. I mean, the same way that everybody’s, dabbling with AI or so many people are dabbling with AI when it comes to writing, right? You don’t want to tell AI to write a paper for you, unless you’re planning on using it just as a starting point to give you some ideas. That’s not just an issue of plagiarism. That’s an issue of, you know, it may not. It may get some things just plain wrong, and you gotta, you gotta be careful with that.

 

Will Bachman  27:14

Well, tell me a little bit of the story of your how your role evolved at Johns Hopkins. You think you’ve been there, what, almost 20 years.

 

Daniel Brotman  27:26

Geez, long time. Yeah. So I came to direct the hospitals program, 2005 and it’s, it’s grown since then, you know, during that time, you know, I’ve gone from up the academic ladder, so I became a full professor, and 2014 have an endowed chair, which is interestingly named after John Flynn, who I had mentioned earlier in this discussion, who had been one of my mentors and residency. And you know, now I’ve got a group of of over 50 faculty that I supervise. And you know, one of the things that happens over time and in any field, but certainly academic medicine, as you transition from being a, you know, frontline provider, to some extent, to a mentor, and you’re helping other people Do things. And, you know, there’s parallels, I’m sure, in almost every field. So, you know, one of the things I really enjoy is, is helping people who are junior and figure out what sort of career paths they seek for themselves, and help them, help them get there. You know, some people are really interested in research. Some people are interested in quality improvement. Some people are interested just in patient care, you know, and, and one of the nice things about hospital medicine is it’s a pretty big tent, so, you know, there’s room for all these types of individuals. And I’ve really got a great, great team of doctors to work with and mentor.

 

Will Bachman  29:21

Tell me about one of the one or two biggest challenges of running, you know, leading a group of 50 hospitalists.

 

Daniel Brotman  29:31

Yes, well, what are, what are the challenges? I think you know, one of the challenges is delegation. You know, I think that that over time it’s become increasingly important to figure out ways that I can trust junior leaders to lead and figure out how to structure you. My supervision of their work and and in a way that that gives them an appropriate amount of autonomy and maintains quality control. So, you know, that was one of the first pieces of advice I got from my department chair when I joined faculty, is, you know, work more on delegation, and I think that that’s certainly something I’ve worked a lot at. And, you know, I think that providing, providing feedback is, is often a big challenge, you know, particularly with with junior leaders, because, you know, I mean, these are all high performing, high achieving individuals who you know, who are really very smart. And you’ve got to be you’ve got to be sensitive. It’s not providing feedback to somebody who’s who’s less experienced and less accomplished, I think you need to be pretty careful and thoughtful about it, so I’m still learning how to do that in a way that I think optimizes results and minimizes things like hurt feelings and so on. You know? I think any area of medicine where you’re in a leadership role, one of the biggest sort of existential challenges is trying to harmonize the economics of what you do with the clinical outcomes or or academic outcomes that matter. Right? Because you know you’re being pressured to save money or cut costs, and the sorts of things, the sorts of levers that you pull to accomplish that potentially can have adverse impacts on the quality of what you’re doing. Right? An easy example that I think many of us have encountered is, you know, you go to your primary care appointment and you know a, they’re running late and B, they only have 10 minutes to see you, right? That’s not their fault. They didn’t go to medicine because they wanted to run late and only have 10 minutes to see you. They went into medicine to to be good doctors and take care of people, but the economics have have gotten in the way of that, and so I think many doctors feel that sort of pressure to be productive when at times that is counter to, you know, forming relationships with patients and giving them all the time and attention that they need. That also applies to other other areas of work, but I think the the patient care is where that hits the hardest.

 

Will Bachman  32:59

Tell me about any courses or professors or activities you were involved in at Harvard that continue to resonate with you. You already talked about the callbacks a little bit, any course or professors that still, you still think about, well, you

 

Daniel Brotman  33:16

know, I ended up doing that year of research and circadian rhythms after taking a course in circadian rhythms, and Reed Hastings was, was one of the professors. Chuck sizer was another professor. And I’m having a slow brain moment remembering one of the third professors that that did that, and and so that that, certainly, you know, made enough of an impact that I wanted to spend a year doing work in that area. I think, you know, as I think back on other other, other courses and activities, certainly the callbacks was was a huge, huge part of what I spent time doing my my junior and senior year. I wasn’t in that group until my junior year, but that was a that was a great time and a wonderful experience. When I think about other other courses and activities, you know, I, I sort of was a bit more of a prototypical science geek than, than, than perhaps I would be if I went to college at this age. But I sort of, you know, had the mindset of, you know, I’m going to learn this as well as I can and plow through it for the most part, as opposed to, I’m going to, you know, really take time to ponder things and explore and and, you know, widen my my horizon. So, you know, yes, it’s a liberal art education, but for people who are sort of on a pre med track. I, you know, so much of it was just making sure that I was mastering, mastering content well enough to pass tests and so on so. So, you know, I think there weren’t, there weren’t a whole lot of courses where I smelled the flowers.

 

Will Bachman  35:20

It sounds like in your answer there, that you were suggesting that now you have a much broader kind of liberal arts type interests. Are you avid theater, film reading like interest expanded since then?

 

Daniel Brotman  35:36

Well, you know, I still am a fan of I love ideas, you know, and not that I didn’t like it, not, not that I didn’t always love ideas. But you know, I, you know, the books that that have have drawn me. As soon as there’s a Michael Lewis book comes out, I’m very quick to gobble that up. Malcolm Gladwell, I think other other miscellaneous books here and there, I tend to go for non fiction and things that focus on ideas more than whimsy, although occasionally i i get dragged into some fiction as well and other activities. Well, you know, tonight we’re we’re going out, I’m going out and my wife and some friends to see the Oscar nominated animated shorts. And then tomorrow we’re doing another activity, which is, I think, embarrassing Valentine’s Day type stories for people who who want to share their their foibles and love. I can’t remember what, what that is called, but should be fun and entertaining, so we get and I still love skiing. You know, I, I was a not very good skier on the ski team my my freshman year of college, and I am getting getting out to Colorado to ski next week. So looking forward to that

 

Will Bachman  37:19

amazing Dan. Thank you so much for joining today. For listeners that want to follow up and keep track of what you’re doing or reach out, where would they find you online

 

Daniel Brotman  37:30

so you can certainly just look up Daniel Brotman, Johns Hopkins, and you know, people are certainly welcome to email me. Last Name, Brotman at J H M, i.edu Johns, Hopkins, medical institutions at Brotman at J H M, i.edu and happy to happy to hear from

 

Will Bachman  37:49

folks, amazing. Dan, thank you so much for joining today. Well, thank

 

Daniel Brotman  37:54

you will for doing this. Really appreciate it. You.